Patient perspectives on improving the depression referral processes in obstetrics settings: a qualitative study

Abstract

Objectives

Although depression screening in obstetrics settings has been recommended, little research exists to guide strategies for screening follow up and depression referral. The purpose of this qualitative study was to inform recommendations for depression screening follow up and referral in obstetrics settings based on responses from a key sample of women about influences on depression treatment use and engagement.

Methods

A stratified purposeful sampling based on pregnancy, socioeconomic status and depression severity was used to identify 23 women who completed semistructured interviews that centered on their beliefs about what would prevent or facilitate entry into depression treatment in the context of obstetrical care. We conducted a thematic analysis through an iterative process of expert transcript review, creation of and refining codes and identifying themes.

Results

Two broad themes influencing depression treatment usage emerged including practical and psychological factors. Among practical factors, women reported a strong preference for treatment provided in the obstetric clinic or in the home with a desire for a proactive referral process and flexible options for receiving treatment. Psychological factors included differing conceptualizations of depression, knowledge about severity and treatment and issues of stigma.

Conclusions

This study suggests that the current standard practice of depression screening and referral to specialty treatment does not match with perceived influences on treatment use among our sample of perinatal women. Recommendations derived from the results for improving follow up with screening and depression referral in obstetrics settings are provided as a platform for further research.

Introduction

The perinatal period is a critical time for the detection and treatment of depression among women because of the prevalence, impact on pregnancy outcomes and the timely contact with the health care system [1], [2]. Despite support for the efficacy of depression treatments, research has consistently indicated that very few women link with care [3], [4]. Approximately 75% of depressed childbearing-aged women in obstetrics/gynecology settings are not detected or treated [3], [5], [6], [7], constituting one of the most important and costly public health problems concerning perinatal women. Because of the risks, screening for depression in obstetrics settings has been commonly recommended in the research literature (e.g., Ref. [8]), adopted as best practice guidelines [9] and mandated as standard medical practice in some states in the US [10]. However, few studies have provided guidance on optimal strategies for screening follow up, referral and linkage to treatment [11]. Adequate depression care has been associated with improved depression and functioning outcomes in primary care samples [12], suggesting the importance of understanding how depression screening and referral processes might more effectively lead to treatment.

Thus, there is a clear momentum towards widespread implementation of screening for depression in prenatal care settings and strikingly little research that would inform clinicians about how to use screening results (i.e., screening feedback, referral and treatment linkage). The purpose of this qualitative study was to identify factors that influence the likelihood of seeking and participating in perinatal depression treatment among untreated depressed women to begin to inform strategies to better address depression in the obstetrics setting. The study employed semistructured interviews with pregnant and postpartum women to identify (1) what women perceive as facilitators and barriers to treatment for depression in the perinatal period and (2) areas of improvement in current practices to bridge the gap between screening and referral follow-through. Based on the results, we present recommendations for health care system-level improvements to the screening and referral process in prenatal care settings, with the ultimate goal of improving engagement with and adherence to depression treatment.